The double burden of under- and over-nutrition in low and middle income countries is a diabetes time bomb. Maternal malnutrition results in babies unequipped to metabolise food, making them highly susceptible to diabetes. This acts as an intergenerational tax on the poorest people, passing poverty and diabetes down from mother to child. Improved maternal nutrition is therefore a vital element of the fight against diabetes.

The association between size at birth and disease later in life has been explained by the concept of foetal programming, with the intrauterine environment assuming great significance in determining the long term prospects of the foetus. A worst case scenario for chronic conditions such as diabetes is an infant with low birth weight (LBW) who then gains weight rapidly in childhood and adult life, which can lead to obesity and diabetes. The tendency for this scenario to happen is increased in low- and middle-income countries undergoing rapid transition.

In many countries, gender bias and discrimination constrain and limit women’s and girls’ rights, choices, capabilities and opportunities, causing them to disproportionately experience hunger, food insecurity and poverty. Twice as many women suffer from malnutrition as men, and girls are twice as likely to die from malnutrition as boys. This pattern is reflected in the nutritional status of women during pregnancy and motherhood.

Maternal nutrition is closely related to a number of factors, including gender equality. Therefore, in countries with high rates of gender equality, diabetes is a ticking time bomb.

A serious threat is the growing evidence that these impacts are not just felt by the offspring of an underweight mother, but that this pattern continues generation after generation. It has been found that women who were malnourished as infants are more likely to give birth to LBW babies, and this relationship can span up to three generations.

As a result of this intergenerational effect, combined with the relationship between LBW and future risk of diabetes, the burden of diabetes has the potential to multiply across generations.

A Maternal Health Issue

Uncontrolled and undiagnosed diabetes during pregnancy threatens both mother and child. Preexisting type 1 and type 2 diabetes can lead to life-threatening complications. Gestational diabetes that is onset or first recognized during pregnancy is also associated with several pregnancy complications and increased future risk of type 2 diabetes for mother and child. Diabetes may already be the leading cause of high risk pregnancies in some countries. Governments must act to end this suffering that affects millions of women and children.

Without pre-conception planning, type 1 and type 2 diabetes can result in a significantly higher risk of maternal and child mortality and morbidity during pregnancy. The reported incidence of maternal mortality of pregnant type 1 diabetic women is 5–20 times higher than that of women without diabetes.

GDM is associated with a threefold risk - perinatal morbidity and mortality, the mother developing type 2 diabetes in the years following her pregnancy, and the infant being predisposed to obesity and diabetes later in their life. Women with GDM often give birth to macrosomic or large-for-gestational age (LGA) infants, which in settings with poor obstetric care can result in life threatening complications for the mother, such as obstructed labour.

Although diabetes may already be the leading cause of high risk pregnancies in some countries, it remains an invisible cause of maternal and child death and is undermining progress in child and maternal health.

In order to accelerate progress on maternal mortality and increase the profile of this neglected issue UN Secretary-General Ban Ki-moon launched the Global Strategy for Women’s and Children’s Health. The strategy recognises that the good health of women and children is vital to progress promotes approaches to maternal and child health to enable them to be drivers for development.

Without action on diabetes, progress in reducing maternal mortality and improving the health of children and mothers is at risk.